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1. Enhanced Recovery Program in High-Risk Patients Undergoing Colorectal Surgery: Results from the PeriOperative Italian Society Registry

Author

Braga, Marco, Pecorelli, Nicolò, Scatizzi, Marco, Borghi, Felice, Missana, Giancarlo, Radrizzani, Danilo, Azzola, Marco, Beretta, Luigi, Bima, Carlo, Bona, Stefano, Bouzari, Hedayat, Casiraghi, Umberto, Ceretti, Andrea Pisani, Crespi, Michele, Ficari, Ferdinando, Iuliani, Riccardo, Maspero, Marianna, Monzani, Roberta, Muratore, Andrea, Pellegrino, Luca, Braga, M, Pecorelli, N, Scatizzi, M, Borghi, F, Missana, G, Radrizzani, D, Azzola, M, Beretta, L, Bima, C, Bona, S, Bouzari, H, Casiraghi, U, Ceretti, A, Crespi, M, Ficari, F, Iuliani, R, Maspero, M, Monzani, R, Muratore, A, Pellegrino, L, and on behalf of the PeriOperative Italian, Society

Subjects
Male, Registrie, Health Status, Health Statu, Postoperative Complications, 0302 clinical medicine, Clinical Protocols, Risk Factors, Retrospective Studie, Medicine, Age Factor, Registries, Postoperative Period, Laparoscopy, Dietary Carbohydrate, Colectomy, Early Ambulation, Aged, 80 and over, medicine.diagnostic_test, Age Factors, Nausea, Middle Aged, Colorectal surgery, Analgesia, Epidural, Italy, Elective Surgical Procedures, Cardiothoracic surgery, 030220 oncology & carcinogenesis, Female, 030211 gastroenterology & hepatology, Guideline Adherence, Elective Surgical Procedure, Human, Urinary Catheter, medicine.medical_specialty, Vomiting, Urinary Catheters, Perioperative Care, 03 medical and health sciences, Dietary Carbohydrates, Humans, Clinical Protocol, Device Removal, Retrospective Studies, Aged, business.industry, Risk Factor, Retrospective cohort study, Recovery of Function, Perioperative, Length of Stay, Vascular surgery, Surgery, Postoperative Complication, business, Abdominal surgery
Abstract

Background: Enhanced recovery after surgery (ERAS) pathways represent the optimal approach for patients undergoing colorectal surgery. Elderly or low physical status patients have been often excluded from ERAS pathways because considered at high risk. The aim of this study is to assess the adherence to ERAS protocol and its impact on short-term postoperative outcome in patients with different surgical risk undergoing elective colorectal resection. Methods: Prospectively collected data entered in an electronic Italian registry specifically designed for ERAS were reviewed. Patients were divided into four groups according to age (70-year-old cutoff) and preoperative physical status as measured by the ASA grade (I–II vs. III–IV). Adherence to 18 ERAS elements and postoperative outcomes were compared between groups. Regression analysis was used to identify independent factors associated with improved outcomes. Results: Eleven Italian hospitals reported data on 706 patients undergoing elective colorectal surgery within an ERAS protocol. Patients with low physical status had reduced adherence to preoperative carbohydrate loading, epidural analgesia, PONV prophylaxis, and early urinary catheter removal. No difference was found between groups for adherence to other perioperative elements. Major complications occurred in 37 (5.2 %) patients without significant differences among groups (p = 0.384). Median (IQR) time to readiness for discharge (TRD) was 4 (3–6) days, length of hospital stay (LOS) was 6 (4–7) days, and both were significantly shorter by only 1 day in the groups of younger patients (p

Published
2016
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2. Enhanced recovery pathway in elderly patients undergoing colorectal surgery: is there an effect of increasing ages? Results from the perioperative Italian Society Registry

Author

Braga, M, Beretta, L, Pecorelli, N, Maspero, M, Casiraghi, U, Borghi, F, Pellegrino, L, Bona, S, Monzani, R, Ferrari, G, Radrizzani, D, Iuliani, R, Bima, C, Scatizzi, M, Missana, G, Guicciardi Marco, A, Muratore, A, Crespi, M, Bouzari, H, Ceretti Andrea, P, Ficari, F, Braga Marco, Beretta Luigi, Pecorelli Nicolò, Maspero Marianna, Casiraghi Umberto, Borghi Felice, Pellegrino Luca, Bona Stefano, Monzani Roberta, Ferrari Gianluigi, Radrizzani Danilo, Iuliani Riccardo, Bima Carlo, Scatizzi Marco, Missana Giancarlo, Guicciardi Marco Azzola, Muratore Andrea, Crespi Michele, Bouzari Hedayat, Ceretti Andrea Pisani, Ficari Ferdinando, Braga, M, Beretta, L, Pecorelli, N, Maspero, M, Casiraghi, U, Borghi, F, Pellegrino, L, Bona, S, Monzani, R, Ferrari, G, Radrizzani, D, Iuliani, R, Bima, C, Scatizzi, M, Missana, G, Guicciardi Marco, A, Muratore, A, Crespi, M, Bouzari, H, Ceretti Andrea, P, Ficari, F, Braga Marco, Beretta Luigi, Pecorelli Nicolò, Maspero Marianna, Casiraghi Umberto, Borghi Felice, Pellegrino Luca, Bona Stefano, Monzani Roberta, Ferrari Gianluigi, Radrizzani Danilo, Iuliani Riccardo, Bima Carlo, Scatizzi Marco, Missana Giancarlo, Guicciardi Marco Azzola, Muratore Andrea, Crespi Michele, Bouzari Hedayat, Ceretti Andrea Pisani, and Ficari Ferdinando

Abstract

Previous studies reported that enhanced recovery pathway (ERP) is safe in elderly who did not require a specifically tailored protocol. In previous studies, elderly have been considered as a homogeneous cohort and the cut-off value to identify them was different. The aim of the present study is to assess the compliance to ERP and its impact on postoperative outcome in three subgroups of elderly patients with increasing ages. Prospectively collected data entered in an electronic Italian registry specifically designed for ERP were reviewed. 315 elderly patients undergoing elective colorectal resection were divided into three groups. Group 1: 71–75 years (n = 105), Group 2: 76–80 years (n = 117), Group 3: over 80 years (n = 93). Primary endpoints of the study were adherence to ERP and time to readiness for discharge (TRD). Compliance to ERP was similar in the three groups. No difference among groups was found for mortality, overall morbidity, major complications, reoperation rate and readmission rate. Median TRD and length of hospital stay (LOS) were progressively longer with increasing age (p = 0.018 and p = 0.078, respectively). Increasing age did not impact on adherence to ERP and postoperative morbidity, but delayed both TRD and LOS.

Published
2018

3. Identification of core items in the enhanced recovery pathway

Author

Braga, M, Scatizzi, M, Borghi, F, Missana, G, Radrizzani, D, Gemma, M, Beretta, L, Bona, S, Monzani, R, Azzola, M, Muratore, A, Crespi, M, Iuliani, R, Bima, C, Bouzari, H, Ceretti, A, Pellegrino, L, Maspero, M, Pecorelli, N, Casiraghi, U, Ficari, F, Braga, Marco, Scatizzi, Marco, Borghi, Felice, Missana, Giancarlo, Radrizzani, Danilo, Gemma, Marco, Beretta, Luigi, Bona, Stefano, Monzani, Roberta, Azzola, Marco, Muratore, Andrea, Crespi, Michele, Iuliani, Riccardo, Bima, Carlo, Bouzari, Hedayat, Ceretti, Andrea Pisani, Pellegrino, Luca, Maspero, Marianna, Pecorelli, Nicolò, Casiraghi, Umberto, Ficari, Ferdinando, Braga, M, Scatizzi, M, Borghi, F, Missana, G, Radrizzani, D, Gemma, M, Beretta, L, Bona, S, Monzani, R, Azzola, M, Muratore, A, Crespi, M, Iuliani, R, Bima, C, Bouzari, H, Ceretti, A, Pellegrino, L, Maspero, M, Pecorelli, N, Casiraghi, U, Ficari, F, Braga, Marco, Scatizzi, Marco, Borghi, Felice, Missana, Giancarlo, Radrizzani, Danilo, Gemma, Marco, Beretta, Luigi, Bona, Stefano, Monzani, Roberta, Azzola, Marco, Muratore, Andrea, Crespi, Michele, Iuliani, Riccardo, Bima, Carlo, Bouzari, Hedayat, Ceretti, Andrea Pisani, Pellegrino, Luca, Maspero, Marianna, Pecorelli, Nicolò, Casiraghi, Umberto, and Ficari, Ferdinando

Abstract

Background & aims: The Enhanced Recovery After Surgery (ERAS) pathway represents an optimal approach in patients undergoing colorectal surgery but complexity in implementing its items could limit its application. The aim of this study is to identify possible core items within an ERAS pathway following elective colorectal resection. Methods: This is a retrospective review of data prospectively collected between January 2014 and September 2015 by 14 Italian Hospitals in an electronic registry dedicated to an ERAS protocol. 722 patients undergoing elective colorectal surgery within an ERAS protocol have been included in the study. Adherence to ERAS items was assessed in all patients. A secondary analysis was restricted to pre- and intraoperative ERAS items. Time to readiness for discharge (TRD) was the primary endpoint of the study. Postoperative overall morbidity was the secondary endpoint. Results: Multivariate analyses showed that active intraoperative warming (p = 0.008), early stop of intravenous fluids (p = 0.0001), and early removal of urinary catheter (p = 0.0001) were associated to a shorter TRD, while early stop of intravenous fluids (p < 0.001) also reduced morbidity. When the analysis was restricted to pre- and intraoperative items, removal of NGT at the end of surgery had an independent role to shorten TRD (p < 0.001) and to reduce overall morbidity (p = 0.019), while the absence of oral bowel preparation reduced postoperative overall morbidity (p = 0.021). Conclusions: In implementing an ERAS pathway, hospitals could initially focus on active intraoperative warming, early stop of intravenous fluids, early removal of urinary catheter, removal of NGT at the end of surgery, and absence of oral bowel preparation, keeping on continuous effort to apply the complete ERAS protocol.

Published
2018

4. Enhanced Recovery Program in High-Risk Patients Undergoing Colorectal Surgery: Results from the PeriOperative Italian Society Registry

Author

Braga, M, Pecorelli, N, Scatizzi, M, Borghi, F, Missana, G, Radrizzani, D, Azzola, M, Beretta, L, Bima, C, Bona, S, Bouzari, H, Casiraghi, U, Ceretti, A, Crespi, M, Ficari, F, Iuliani, R, Maspero, M, Monzani, R, Muratore, A, Pellegrino, L, Braga, Marco, Pecorelli, Nicolò, Scatizzi, Marco, Borghi, Felice, Missana, Giancarlo, Radrizzani, Danilo, Azzola, Marco, Beretta, Luigi, Bima, Carlo, Bona, Stefano, Bouzari, Hedayat, Casiraghi, Umberto, Ceretti, Andrea Pisani, Crespi, Michele, Ficari, Ferdinando, Iuliani, Riccardo, Maspero, Marianna, Monzani, Roberta, Muratore, Andrea, Pellegrino, Luca, Braga, M, Pecorelli, N, Scatizzi, M, Borghi, F, Missana, G, Radrizzani, D, Azzola, M, Beretta, L, Bima, C, Bona, S, Bouzari, H, Casiraghi, U, Ceretti, A, Crespi, M, Ficari, F, Iuliani, R, Maspero, M, Monzani, R, Muratore, A, Pellegrino, L, Braga, Marco, Pecorelli, Nicolò, Scatizzi, Marco, Borghi, Felice, Missana, Giancarlo, Radrizzani, Danilo, Azzola, Marco, Beretta, Luigi, Bima, Carlo, Bona, Stefano, Bouzari, Hedayat, Casiraghi, Umberto, Ceretti, Andrea Pisani, Crespi, Michele, Ficari, Ferdinando, Iuliani, Riccardo, Maspero, Marianna, Monzani, Roberta, Muratore, Andrea, and Pellegrino, Luca

Abstract

Background: Enhanced recovery after surgery (ERAS) pathways represent the optimal approach for patients undergoing colorectal surgery. Elderly or low physical status patients have been often excluded from ERAS pathways because considered at high risk. The aim of this study is to assess the adherence to ERAS protocol and its impact on short-term postoperative outcome in patients with different surgical risk undergoing elective colorectal resection. Methods: Prospectively collected data entered in an electronic Italian registry specifically designed for ERAS were reviewed. Patients were divided into four groups according to age (70-year-old cutoff) and preoperative physical status as measured by the ASA grade (I–II vs. III–IV). Adherence to 18 ERAS elements and postoperative outcomes were compared between groups. Regression analysis was used to identify independent factors associated with improved outcomes. Results: Eleven Italian hospitals reported data on 706 patients undergoing elective colorectal surgery within an ERAS protocol. Patients with low physical status had reduced adherence to preoperative carbohydrate loading, epidural analgesia, PONV prophylaxis, and early urinary catheter removal. No difference was found between groups for adherence to other perioperative elements. Major complications occurred in 37 (5.2 %) patients without significant differences among groups (p = 0.384). Median (IQR) time to readiness for discharge (TRD) was 4 (3–6) days, length of hospital stay (LOS) was 6 (4–7) days, and both were significantly shorter by only 1 day in the groups of younger patients (p < 0.001). At multivariate analysis, laparoscopy increased adherence to ERAS items and reduced TRD, LOS, and morbidity. A high ASA grade was significantly associated with lower adherence, whereas older age significantly prolonged TRD and LOS. Conclusion: ERAS pathway can be safely applied in elderly and low physical status patients yielding slight differences in postoperative morbidi

Published
2017

5. Identification of core items in the enhanced recovery pathway

Author

Hedayat Bouzari, Umberto Casiraghi, Felice Borghi, Marco Azzola, Ferdinando Ficari, Andrea Pisani Ceretti, Riccardo Iuliani, Luigi Beretta, Marianna Maspero, Marco Scatizzi, Stefano Bona, Roberta Monzani, Luca Pellegrino, Danilo Radrizzani, Andrea Muratore, Giancarlo Missana, Michele Crespi, Nicolò Pecorelli, Marco Braga, Carlo Bima, Marco Gemma, Braga, M, Scatizzi, M, Borghi, F, Missana, G, Radrizzani, D, Gemma, M, Beretta, L, Bona, S, Monzani, R, Azzola, M, Muratore, A, Crespi, M, Iuliani, R, Bima, C, Bouzari, H, Ceretti, A, Pellegrino, L, Maspero, M, Pecorelli, N, Casiraghi, U, Ficari, F, Braga, Marco, Scatizzi, Marco, Borghi, Felice, Missana, Giancarlo, Radrizzani, Danilo, Gemma, Marco, Beretta, Luigi, Bona, Stefano, Monzani, Roberta, Azzola, Marco, Muratore, Andrea, Crespi, Michele, Iuliani, Riccardo, Bima, Carlo, Bouzari, Hedayat, Ceretti, Andrea Pisani, Pellegrino, Luca, Maspero, Marianna, Pecorelli, Nicolò, Casiraghi, Umberto, and Ficari, Ferdinando

Subjects
Male, medicine.medical_specialty, Time Factors, Multivariate analysis, Colon, Health Status, Endocrinology, Diabetes and Metabolism, Postoperative morbidity, Perioperative Care, 03 medical and health sciences, Postoperative Complications, 0302 clinical medicine, Endocrinology, Enhanced recovery, Core ERAS item, Risk Factors, Colorectal surgery, Secondary analysis, Clinical endpoint, medicine, Humans, In patient, Hospital Mortality, Registries, Urinary catheter, Digestive System Surgical Procedures, Aged, Retrospective Studies, Core (anatomy), Hospital stay, Nutrition and Dietetics, business.industry, Rectum, Recovery of Function, Length of Stay, Middle Aged, Patient Discharge, Surgery, Diabetes and Metabolism, Outcome and Process Assessment, Health Care, Treatment Outcome, Italy, 030220 oncology & carcinogenesis, Female, 030211 gastroenterology & hepatology, business
Abstract

Background & aims: The Enhanced Recovery After Surgery (ERAS) pathway represents an optimal approach in patients undergoing colorectal surgery but complexity in implementing its items could limit its application. The aim of this study is to identify possible core items within an ERAS pathway following elective colorectal resection. Methods: This is a retrospective review of data prospectively collected between January 2014 and September 2015 by 14 Italian Hospitals in an electronic registry dedicated to an ERAS protocol. 722 patients undergoing elective colorectal surgery within an ERAS protocol have been included in the study. Adherence to ERAS items was assessed in all patients. A secondary analysis was restricted to pre- and intraoperative ERAS items. Time to readiness for discharge (TRD) was the primary endpoint of the study. Postoperative overall morbidity was the secondary endpoint. Results: Multivariate analyses showed that active intraoperative warming (p = 0.008), early stop of intravenous fluids (p = 0.0001), and early removal of urinary catheter (p = 0.0001) were associated to a shorter TRD, while early stop of intravenous fluids (p < 0.001) also reduced morbidity. When the analysis was restricted to pre- and intraoperative items, removal of NGT at the end of surgery had an independent role to shorten TRD (p < 0.001) and to reduce overall morbidity (p = 0.019), while the absence of oral bowel preparation reduced postoperative overall morbidity (p = 0.021). Conclusions: In implementing an ERAS pathway, hospitals could initially focus on active intraoperative warming, early stop of intravenous fluids, early removal of urinary catheter, removal of NGT at the end of surgery, and absence of oral bowel preparation, keeping on continuous effort to apply the complete ERAS protocol.

Published
2018

6. Enhanced recovery pathway in elderly patients undergoing colorectal surgery: is there an effect of increasing ages? Results from the perioperative Italian Society Registry

Author

Marco Braga, Stefano Bona, Gianluigi Ferrari, Andrea Muratore, Riccardo Iuliani, Luigi Beretta, Luca Pellegrino, Marianna Maspero, Giancarlo Missana, Marco Scatizzi, Michele Crespi, Marco Azzola Guicciardi, Ferdinando Ficari, Felice Borghi, Roberta Monzani, Danilo Radrizzani, Hedayat Bouzari, Andrea Pisani Ceretti, Umberto Casiraghi, Nicolò Pecorelli, Carlo Bima, Braga, M, Beretta, L, Pecorelli, N, Maspero, M, Casiraghi, U, Borghi, F, Pellegrino, L, Bona, S, Monzani, R, Ferrari, G, Radrizzani, D, Iuliani, R, Bima, C, Scatizzi, M, Missana, G, Guicciardi Marco, A, Muratore, A, Crespi, M, Bouzari, H, Ceretti Andrea, P, Ficari, F, Braga, Marco, Beretta, Luigi, Pecorelli, Nicolò, Maspero, Marianna, Casiraghi, Umberto, Borghi, Felice, Pellegrino, Luca, Bona, Stefano, Monzani, Roberta, Ferrari, Gianluigi, Radrizzani, Danilo, Iuliani, Riccardo, Bima, Carlo, Scatizzi, Marco, Missana, Giancarlo, Guicciardi, Marco Azzola, Muratore, Andrea, Crespi, Michele, Bouzari, Hedayat, Ceretti, Andrea Pisani, and Ficari, Ferdinando

Subjects
Reoperation, medicine.medical_specialty, Postoperative morbidity, Patient Readmission, Perioperative Care, 03 medical and health sciences, 0302 clinical medicine, Elderly, Postoperative Complications, Enhanced recovery, Colorectal surgery, Medicine, Postoperative outcome, Humans, Major complication, Registries, Colectomy, Aged, Retrospective Studies, Aged, 80 and over, business.industry, Age Factors, Rectum, Perioperative, Length of Stay, Readmission rate, Surgery, Treatment Outcome, Italy, Homogeneous, 030220 oncology & carcinogenesis, Cohort, Practice Guidelines as Topic, Length of stay, 030211 gastroenterology & hepatology, Guideline Adherence, business, Enhanced recovery after surgery, Follow-Up Studies
Abstract

Previous studies reported that enhanced recovery pathway (ERP) is safe in elderly who did not require a specifically tailored protocol. In previous studies, elderly have been considered as a homogeneous cohort and the cut-off value to identify them was different. The aim of the present study is to assess the compliance to ERP and its impact on postoperative outcome in three subgroups of elderly patients with increasing ages. Prospectively collected data entered in an electronic Italian registry specifically designed for ERP were reviewed. 315 elderly patients undergoing elective colorectal resection were divided into three groups. Group 1: 71-75years (n=105), Group 2: 76-80years (n=117), Group 3: over 80years (n=93). Primary endpoints of the study were adherence to ERP and time to readiness for discharge (TRD). Compliance to ERP was similar in the three groups. No difference among groups was found for mortality, overall morbidity, major complications, reoperation rate and readmission rate. Median TRD and length of hospital stay (LOS) were progressively longer with increasing age (p=0.018 and p=0.078, respectively). Increasing age did not impact on adherence to ERP and postoperative morbidity, but delayed both TRD and LOS.

Published
2017

7. Impact of laparoscopy on adherence to an enhanced recovery pathway and readiness for discharge in elective colorectal surgery: Results from the PeriOperative Italian Society registry

Author

Braga, M, Borghi, F, Scatizzi, M, Missana, G, Guicciardi, MA, Bona, S, Ficari, F, Maspero, M, Pecorelli, N, Pellegrino, L, Radrizzani, D, Beretta, L, Casiraghi, U, Muratore, A, Crespi, M, Iuliani, R, Bima, C, Bouzari, H, Ceretti, A, Braga, M, Borghi, F, Scatizzi, M, Missana, G, Guicciardi, M, Bona, S, Ficari, F, Maspero, M, Pecorelli, N, Pellegrino, L, Radrizzani, D, Beretta, L, Casiraghi, U, Muratore, A, Crespi, M, Iuliani, R, Bima, C, Bouzari, H, Ceretti, A, Braga, Marco, Borghi, Felice, Scatizzi, Marco, Missana, Giancarlo, Guicciardi, Marco Azzola, Bona, Stefano, Ficari, Ferdinando, Maspero, Marianna, Pecorelli, Nicolo, on behalf of PeriOperative Italian, Society, and Beretta, Luigi

Subjects
Laparoscopic surgery, Adult, Male, Registrie, medicine.medical_specialty, Enhanced recovery pathway, medicine.medical_treatment, 03 medical and health sciences, 0302 clinical medicine, Time to readiness for discharge, Colorectal surgery, Retrospective Studie, medicine, Humans, Prospective Studies, Registries, Postoperative Period, Prospective cohort study, Laparoscopy, Retrospective Studies, Aged, Postoperative Care, medicine.diagnostic_test, Elective Surgical Procedure, business.industry, Retrospective cohort study, Perioperative, Length of Stay, Middle Aged, Length of hospital stay, Conversion to Open Surgery, Patient Discharge, Surgery, Postoperative complication, Prospective Studie, Italy, Elective Surgical Procedures, 030220 oncology & carcinogenesis, 030211 gastroenterology & hepatology, Female, Guideline Adherence, business, Abdominal surgery, Human
Abstract

Introduction: Previous studies reported that laparoscopic surgery (LPS) improved postoperative outcomes in patients undergoing colorectal surgery within an enhanced recovery program (ERP). However, the effect of minimally invasive surgery on each ERP item has not been clarified, yet. The aim of this study is to assess the impact of LPS on adherence to ERP items and recovery as measured by time to readiness for discharge (TRD). Methods: Prospectively collected data entered in an electronic Italian registry specifically designed for ERP were reviewed. Patients undergoing elective colorectal surgery were divided into three groups: successful laparoscopy, conversion to open surgery, primary open surgery. Adherence to 19 ERP elements and postoperative outcomes were compared among groups. Multivariate regression analysis was used to identify whether LPS had an independent role to improve ERP adherence and postoperative outcomes. Results: 714 patients (successful LPS 531, converted 42, open 141) underwent elective colorectal surgery within an ERP. Epidural analgesia was used in the 75.1% of open group patients versus 49.9% of LPS group patients (p = 0.012). After surgery, oral feeding recovery, i.v. fluids suspension, removal of both urinary and epidural catheters occurred earlier in the LPS group both in the overall series and in uneventful patients only. Mean TRD and length of hospital stay were significantly shorter in the LPS group (p < 0.001 for both). Overall morbidity rate was 18.7% in the LPS group versus 32.6% in the open group (p = 0.001). At multivariate analysis, LPS was significantly associated to an increased adherence to postoperative ERP items, a shorter TRD, and a reduced overall morbidity, whereas rectal surgery and new stoma formation impaired postoperative recovery. Conclusions: The present study showed that a successful laparoscopic procedure had an independent role to increase the adherence to postoperative ERP and to improve short-term postoperative outcome.

Published
2017

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